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Safety Recommendation Details

Safety Recommendation A-11-029
Details
Synopsis: On July 31, 2008, about 0945 central daylight time, East Coast Jets flight 81, a Hawker Beechcraft Corporation 125-800A airplane, N818MV, crashed while attempting to go around after landing on runway 30 at Owatonna Degner Regional Airport (OWA), Owatonna, Minnesota. The two pilots and six passengers were killed, and the airplane was destroyed by impact forces. The nonscheduled, domestic passenger flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 135. An instrument flight rules flight plan had been filed and activated; however, it was canceled before the landing. Visual meteorological conditions prevailed at the time of the accident. The National Transportation Safety Board (NTSB) determined that the probable cause of this accident was the captain’s decision to attempt a go-around late in the landing roll with insufficient runway remaining. Contributing to the accident were (1) the pilots’ poor crew coordination and lack of cockpit discipline; (2) fatigue, which likely impaired both pilots’ performance; and (3) the failure of the Federal Aviation Administration (FAA) to require crew resource management (CRM) training and standard operating procedures (SOPs) for 14 CFR Part 135 operators.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Inform operators of airplanes that have wet runway landing distance data based on the British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X1591 that the data contained in the Aircraft Flight Manuals (and/or performance supplemental materials) may underestimate the landing distance required to land on wet, ungrooved runways and work with industry to provide guidance to these operators on how to conduct landing distance assessments when landing on such runways.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Owatonna, MN, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA08MA085
Accident Reports: Crash During Attempted Go-Around After Landing East Coast Jets Flight 81 Hawker Beechcraft Corporation 125-800A, N818MV
Report #: AAR-11-01
Accident Date: 7/31/2008
Issue Date: 3/29/2011
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s): Runway Safety

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/4/2015
Response: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) draft Advisory Circulars (AC) 25-X, “Takeoff Performance Data for Operations on Contaminated Runways,” and AC 25-X, “Landing Performance Data for Time-of-Arrival Landing Performance Assessments,” which were posted for comment on the FAA’s website on January 21, 2015. Both of these draft ACs provide guidance and standardized methods that data providers, such as type certificate (TC) holders, supplemental type certificate (STC) holders, applicants, and airplane operators can use when developing performance data for transport category airplanes for operations on contaminated runways. The AC also promotes the use of consistent terminology for runway surface conditions used among data providers and FAA personnel. The NTSB has investigated several accidents within the last 10 years that involve issues addressed by these ACs. As a result of these investigations, the NTSB issued Safety Recommendations A 07 57 through 64, A 08 17, A 08 41 through 43, and A 11 28 and 29.

From: NTSB
To: FAA
Date: 11/13/2012
Response: The FAA analyzed certain information that the NTSB had presented in a number of factual reports available in the docket for the Owatonna accident investigation. Safety Recommendation A-11-29 was issued based on analysis that the NTSB had performed that was discussed in one of these reports, the Group Chairman’s Aircraft Performance Study Addendum #1 (the Addendum). Specifically, the FAA disagreed with, and reanalyzed, the finding in the Addendum that no more than 3 millimeters (mm) of standing water was present on the runway at the time the crash occurred. If 3 mm or more of standing water had been present on the runway at the time of the accident, there is an increased likelihood that dynamic hydroplaning reduced the braking performance of the accident aircraft. The FAA reviewed certain other information, contained in the meteorological factual report and the witness group chairman’s factual report (both of which are also included in the Owatonna docket), to conclude that there had been significant water on the runway surface at the time of the accident and that, therefore, hydroplaning was likely. The FAA cited the following: • A picture taken by a parking lot security camera picture outside a Cabela's Sporting Goods store, located about a mile from the crash site, which was included in the meteorological factual report. The FAA believes that the picture, taken within minutes of the crash time, shows water standing in the parking lot that is more than 3 mm deep. • A statement from a witness, who had been located one-half mile from the runway, who observed a 20-foot rooster tail of spray behind the airplane all the way down the runway. This statement was included in the witness group chairman’s factual report. The Addendum recognizes the uncertainties associated with the accident, but notes that the airplane flight manual data could only have been consistent with the observed results if the airplane had experienced dynamic hydroplaning, which implies that the runway had been flooded with at least 3 mm of standing water. The FAA’s analysis found a similar result. Whether or not the runway was flooded, leading to dynamic hydroplaning, is key to much of the basis for this recommendation. The Addendum examined this question rigorously, and relied on what we believe to be more reliable indications than the above information, which the FAA used in reaching its conclusions. Rather than relying on a picture of a parking lot, taken a mile from the runway and subject to its own rainwater drainage and runoff conditions, the analysis in the Addendum relied on measurements of the runway cross slope, runway macrotexture, and recorded rainfall rate, together with a model for runway drainage provided by the Texas Transportation Institute (TTI) to compute the likely depth of water on the runway at the time of the accident. The TTI model calculated the water depth to be only about 1 mm, even for the maximum assumed rainfall rate, significantly less than the 3 mm of water necessary for hydroplaning. The FAA’s letter quoted only part of the conclusion stated in the Addendum; below is the full conclusion: Given the measured rainfall on the day of the accident, the OWA [Owatonna] runway cross-slope gradient and surface macrotexture do not support a conclusion that the runway could have been flooded at the time of the accident, or that the airplane could have experienced dynamic hydroplaning during the landing roll. A witness observation of “rooster tails” behind the accident airplane is a piece of information that the FAA cites as supporting hydroplaning. We believe, and are supported in this view by an expert from the National Aeronautics and Space Administration who performed much of the fundamental research on tire friction and runway surface conditions, that rooster tails are evidence against hydroplaning. In order for rooster tails to arise, the airplane’s tires must be spinning; the spinning tires kick up water from the macrotexture of the runway. If the airplane is hydroplaning, the tires are not spinning, and therefore no rooster tails occur. It also appears that the FAA’s analysis did not consider the extensive comparisons made in the Addendum between the Advisory Material Joint 25X1591 wet runway braking coefficients and the Federal Aviation Regulations (FAR) 25.109 wet runway braking coefficients that were considered by the FAA’s takeoff and landing performance assessment aviation rulemaking committee (TALPA ARC). The Addendum provides evidence that the wet runway braking coefficients assumed in 25X1591 are substantially higher than those of the TALPA ARC’s recommendations, which are based on FAR 25.109. In its letter, the FAA concluded (1) that the data used to question the landing distance data derived from BCAR Reference Wet Hard Surface or Advisory Material Joint 25X1591 are based on only one accident with many unknown factors and (2) that more testing is required to make a case that these landing distances are underestimated. We agree that more testing is needed; however, the FAA does not plan to perform this testing, or otherwise to address the safety problem documented in the Addendum. We do not agree that the FAA has effectively addressed this recommendation; in particular, we believe that the analysis it performed was incomplete and incorrect (for example, indicating that a rooster tail is evidence of hydroplaning). Accordingly, we ask the FAA to reconsider its position. In the meantime, pending the FAA’s taking the recommended action, Safety Recommendation A-11-29 is classified OPEN—UNACCEPTABLE RESPONSE. We are currently investigating a number of accidents and incidents involving turbojet airplane overruns while landing on wet runways. Mounting evidence from the American Airlines B737-823 landing overrun in Kingston, Jamaica, in December 2009, the Southwest Airlines B737-700W landing overrun at Midway Airport, Chicago, Illinois, in April 2011, flight operations quality assurance programs, and manufacturer certification flight test data for several transport category airplane models suggests that the stopping performance levels embedded in the FAR 25.109 standard may not be representative of actual turbojet airplane stopping performance on representative wet, grooved or wet, ungrooved runways. These investigations suggest that similar issues exist with other airplanes, and, in the near future, we may issue more recommendations addressing these issues. We note that the Addendum provided an example of our concern, in the following conclusion: 8. The Roswell B737 tests also indicate that the actual braking performance achieved on some ungrooved, wet runways may be below that produced by the combination of µmax and ?AS specified in FAR 25.109. These results underscore the importance of testing the actual ?AS achieved on a wet, ungrooved runway during certification, and ensuring that the values of µmax and ?AS determined from the tests are consistent with the actual landing distances achieved by the airplane during the tests.

From: FAA
To: NTSB
Date: 8/21/2012
Response: -From Michael P. Huerta, Acting Administrator: The Federal Aviation Administration (FAA) Aircraft Evaluation Groups (AEG) in Kansas City, Long Beach, and Seattle; the FAA Wichita Aircraft Certification Office; and Hawker Beechcraft Corporation (HBC) all reviewed the accident report and related documents associated with this recommendation. HBC believes that the data provided in the Aircraft Flight Manual (AFM) for the HBC Model 125-800A is accurate and supported with actual flight test data performed in Hatfield, United Kingdom when the original British Aerospace (BAE) 125-800A was tested. The landing performance information contained in the AFMs of the 13Ae 125 family of aircraft has been successfully applied by flightcrews for nearly 50 years. Key to this recommendation is the "NTSB Aircraft Performance Group Study" results. The study concluded that, assuming sufficient braking effort throughout the landing roll, the available accident data, in this case, is most consistent with a simulation-based landing performance calculation with the following conditions: runway flooded with water 3 millimeters deep; flaps at 45 degrees; lift dump not deployed; tail wind of approximately 8 knots; airspeed over the threshold at reference landing speed (122 knots calibrated airspeed); and touchdown a l 130 knots groundspeed, 1,128 feet from the threshold. The study also states: The actual condition on the runway, tailwind magnitude, state of the lift-dump system, airspeed at touchdown, and braking effort are unknown, so it is possible that other combinations of these variables could also produce results consistent with the available data. The available data does indicate that the deceleration achieved by the airplane after touchdown was less than what simulation results predict for a landing at flaps 25, on a wet (but not flooded) runway, and a 10 knot tailwind . The reasons for the lack of deceleration on the accident night cannot be determined conclusively from the available performance information. The study concludes the wet runway landing distances published in the BAE 125-800A AFM and computed by the HBC Computerized Aircraft Performance System (CAPS) may be based on braking coefficients that are higher than those that the braking system can actually attain. Consequently, the AFM and CAPS di stances for wet runway conditions may be less than what the airplane will actually requi re to land. The study also concluded that, "[given] the measured rainfall, the runway could not be flooded at the time or the accident and the airplane could not have hydroplaned." Key to the stud y's conclusions is the assumption that the accident runway did not have more than 3 millimeters of standing water. However, the "NTSB Meteorological Factual Report," dated October 9, 2008, shows a parking lot security camera picture from a Cabela’s Sporting Goods store, which is located about a mile from the crash site. The picture was taken within minutes or the crash time. In the FAA's estimation, this picture shows water standing in the parking lot that is more than 3 millimeters. Further, the "NTSB Witness Group Chairman's Factual Report," dated September 30, 2008, provides a witness one-half mile from the runway observing a 20 foot rooster tail of spray behind the airplane all the way down the runway. We believe this indicates significant water on the runway surface at the time of the accident. The HBC responded to the study in a party submission on February 22, 2011. The party submission states that the study does not factually prove that the 125 series AFM and supplements underestimate the landing distance required to land on wet, ungrooved runways. The study's enclosures included excerpts of HBC's party submission to the NTSB. The FAA AEG calculated the landing distance for three runway conditions using the AFM data for the 125-800A given the following aircraft and environmental conditions: flaps at 45 degrees; aircraft landing weight of 19,912 lbs; airport elevation of 1.145 fee t; and tailwind of 8 knots. The procedure to achieve the shortest practicable landing distance requires a touchdown within 800 feet of the runway threshold, selection or the lift dump, and rapid application of full braking. Using the HBC landing charts, we determined the unfactored gross landing distance required from 50 feet to stop on a dry, wet, or slippery runway surface. We interpolated the data slope halfway between the wet runway line (approximately 4,200 feet ) and slippery runway line (off scale high of over 10,000 feet); we calculated approximately 6,500 feel, which is very consistent with actual crash results. This required an assumption that the runway had more than 3 millimeters standing water. Supporting our reasoning to interpolate between the wet and slippery lines on the AFM landing distance chart was thunderstorms passing over the airport, eye witness reports, and the surveillance picture at the Cabela's parking lot, as previously stated. The data used to question the landing distance data derived from British Civil Air Regulations Reference Wet Hard Surface or Advisory Material Joint 25X159 1 is based on one accident with many unknown factors. These include the actual amount of water on the runway, exact tailwind, pilot's braking effort, airspeed, ground speed at touchdown, touchdown point on the runway, and the actual track down the runway after touchdown. We believe that more testing would be required to make a case that these landing di stances are underestimated. The FAA's Pilot's Handbook of Aeronautical Knowledge and Airplane Flying Handbook inform pilots of the difficulties and considerations for landing on less than ideal runway conditions and surfaces, including a warning to expect adverse braking effectiveness due to wet runway surfaces. Additionally, on October 20, 2009, the FAA issued Safety Alert for Operators 09015. Training for Maximum Performance Landing on Contaminated Runways, urging the proper application of aircraft landing performance data, and that operators articulate a process for conducting a landing distance assessment under the conditions existing at the time of arrival. I believe that the FAA has effectively addressed this recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 9/6/2011
Response: The NTSB notes that the FAA is currently reviewing the studies and reports applicable to this recommendation and plans to evaluate which airplanes base their wet runway landing distance data on the British Civil Air Regulations Reference. Once this review and evaluation is complete, the FAA will determine how to respond to the results. Pending completion of the recommended action, Safety Recommendation A-11-29 is classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/10/2011
Response: CC# 201100245: - From J. Randolph Babbitt, Administrator: The FAA is reviewing the studies and reports applicable to this recommendation that the Board evaluated for this accident, which includes the Aircraft Performance Study. The FAA also plans to evaluate which airplanes base their wet runway landing distance data on the British Civil Air Regulations Reference, Wet Hard Surface or Advisory Material Joint 25X1591. Once the review and evaluation is complete, the FAA will determine how best to address this recon1mendation. I will keep the Board informed of the FAA's progress on this safety recommendation, and I will provide an update by July 2012.